Economic and Social Council

Distr. GENERAL 15 January 1996ORIGINAL:
ENGLISH

COMMISSION ON POPULATION AND DEVELOPMENT
Twenty-ninth session
26 February-1 March 1996
Item 4 of the provisional agenda*
FOLLOW-UP ACTIONS TO THE RECOMMENDATIONS
OF THE INTERNATIONAL CONFERENCE ON POPULATION AND DEVELOPMENT:
REPRODUCTIVE RIGHTS AND REPRODUCTIVE HEALTH
Concise report on world population monitoring, 1996:
reproductive rights and reproductive health
Report of the Secretary-General
*E/CN.9/1996/1.
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CONTENTS
Paragraphs
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . 1- 7
I. ENTRY INTO REPRODUCTIVE LIFE . . . . . . . . . 8-22
II. REPRODUCTIVE BEHAVIOUR. . . . . . . . . . . . 23-37
III. CONTRACEPTION. . . . . . . . . . . . . . . . . 38-50
IV. ABORTION . . . . . . . . . . . . . . . . . . . 51-59
V. MATERNAL MORTALITY AND MORBIDITY . . . . . . . 60-71
VI. SEXUALLY TRANSMITTED DISEASES, INCLUDING
HIV/AIDS . . . . . . . . . . . . . . . . . . . 72-85
VII. REPRODUCTIVE RIGHTS . . . . . . . . . . . . . 86-94
VIII. POPULATION INFORMATION, EDUCATION AND
COMMUNICATION . . . . . . . . . . . . . . . . 95-103
Tables
1. Average prevalence of specific contraceptive methods,
by region
2. Estimates of maternal deaths and maternal mortality
ratios, 1990
3. Estimated global incidence and mortality from main
obstetric complication worldwide, 1995
4. Effect of pregnancy complications on mother and baby
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INTRODUCTION
1. Reproductive health has been defined as a state of complete
physical, mental and social well-being and not merely the absence of
disease or infirmity in all matters relating to the reproductive
system and to its functions and processes (United Nations, 1995a).
Thus, reproductive health goes beyond the child-bearing ages to
encompass problems that may arise in both the earlier and the post-
reproductive years. Further, reproductive health implies that people
are able to have a satisfying and safe sex life and that they have
the capability to reproduce and the freedom to decide if, when and
how often to do so. The attainment of reproductive health also
enables women to go safely through pregnancy and childbirth and
provides couples with the best chance of having a healthy infant
(United Nations, 1995a)
2. Reproductive rights are central to the achievement of
reproductive health. Reproductive rights embrace certain human
rights that are already recognized in national laws, international
human rights instruments and other consensus documents. The
definition of reproductive rights recognizes the basic right of
couples and individuals to decide freely and responsibly the number,
spacing and timing of their children and to have the information and
means to do so, and the right to make decisions concerning
reproduction, free of discrimination, coercion and violence (United
Nations, 1995a). Implicit in this is the right of men and women to
be informed about and to have access to safe, effective, affordable
and acceptable methods of family planning of their choice
3. The broad and comprehensive approach to reproductive health
reflected in the above definitions contrasts with various previous
approaches dealing with reproduction. Those earlier approaches
focused on specific aspects of reproductive health. Family planning
programmes, for example, have concentrated on providing information
and services on contraception. Maternal and child health programmes
have similarly focused on promoting the health of mothers and their
young children, while safe motherhood programmes have emphasized the
need to ensure that pregnant women receive adequate prenatal care,
safe delivery and postnatal care. They have also sought to address
the high risks that women in many contexts face in relation to
child-bearing
4. Reproductive health incorporates all of those aspects in a
comprehensive manner. While acknowledging the importance of family
planning, the approach recognizes that reproductive health is not
limited to child-bearing ages alone and that reproductive health
concerns men as well as women. It also recognizes that to address
reproductive health issues successfully, there is a need to address
the reproductive rights of men and women and the social behaviour and
cultural practices that affect reproductive health outcomes.
5. The approach to reproductive health is based on the premise
that the health status of individuals at any given time is affected
by their experiences at earlier ages. The reproductive health of men
and women in child-bearing ages, for example, reflects not only their
current experiences but also their health status during infancy,
childhood and adolescence. Similarly, health status beyond the
reproductive ages may reflect reproductive experiences at earlier
life stages. The experiences of one generation also have
implications for the health of the next generation
6. The present report provides a global review of selected aspects
of reproductive rights and reproductive health. The topics covered
include entry into reproductive life; reproductive behaviour;
contraception; abortion; maternal mortality and morbidity; sexually
transmitted diseases, including human immunodeficiency virus (HIV)
and acquired immunodeficiency syndrome (AIDS); policy issues related
to reproductive rights; and as population information, education and
communication with respect to reproductive rights and reproductive
health
7. To the extent possible, the reproductive rights and
reproductive health of both men and women have been reviewed in the
present report. However, data collection and research have until
recently focused primarily on the reproductive and contraceptive
behaviour of women. It is only during the past few years that
demographic and health surveys have begun to include samples of men.
The need to collect data and to conduct research on the reproductive
attitudes and behaviour of both men and women has become more
imperative given the renewed emphasis on the shared responsibility
of partners in matters related to reproduction. Information is also
lacking on the reproductive health of adolescents and of older men
and women, who are usually not the subject of inquiry in demographic
and health surveys
I. ENTRY INTO REPRODUCTIVE LIFE
8. Initiation of reproductive capability generally occurs in the
second decade of life. The events which define entry into
reproductive life, and their timing, are important determinants of
both fertility and reproductive health and have important
implications for the future life course of individuals. The stage
of life during which individuals reach sexual maturity has come to
be known as adolescence. Adolescence is the period of transition
from childhood to adulthood. Although the change is biological, the
duration and nature of adolescence is primarily a social construct
and thus varies greatly from culture to culture. This review refers
to the age range of 10-24 years but focuses mostly on age group
15-24, which the World Health Organization (WHO) refers to as young
people. Within this age span lies much of the variation seen between
countries and population subgroups in the events that define the
beginning of reproductive life
9. Adolescence is a period of development that is increasingly
recognized both as an important determinant of future health and as
a specially vulnerable period of life. In particular, increasing
concern has been expressed about sexual risk-taking among young
people, and the consequences of such behaviour, such as teenage
pregnancy and the occurrence of sexually transmitted diseases,
including HIV. The challenges of addressing the needs of adolescents
are compounded by demographic factors. It has been estimated that
in 1995 young people (ages 15-24 years) make up over 14 per cent of
the total population in more developed regions and almost 20 per cent
in the less developed regions (United Nations, 1995b)
10. In a number of societies, menarche signifies maturity and the
readiness to marry or commence sexual activity. Studies documenting
the age at menarche show that the age of onset varies by
approximately five years between different population groups. The
average age for each region indicates a younger age at onset in the
more developed than in the less developed regions. Age at menarche
has fallen in most developed countries. In developing countries, the
decline is less well documented, but there is some evidence of a fall
in age at onset in a number of population groups. The fall in age
at menarche implies an earlier potential to reproduce. However, in
general, it would appear that the effect of this biological factor
has been offset by other influences, especially by increases in age
at first marriage
11. Traditionally, age at marriage has been regarded as marking the
initiation of sexual activity and, therefore, the beginning of
exposure to reproduction. Marriage may take widely different forms,
ranging from formal unions approved under civil or religious law, to
cohabiting or even visiting relationships. Despite the difficulties
surrounding definitions of marriage, it is possible to identify some
broad patterns in the timing of the beginning of sexual exposure of
young women and men by examining the age at marriage
12. Changes in the timing of first marriage around the world are
well documented and it is clear that age at first marriage among
women has risen dramatically in many countries. In the developing
countries with data from the Demographic and Health Surveys (DHS),
changes in the age at marriage can be examined by comparing the
experience of women in different cohorts. The surveys use a broad
definition of marriage which includes both formalized and informal
unions. The data indicate that the proportion married by age 20
among young women (those aged 20-24 at the time of the survey) is
considerably lower than that among older women (aged 40-44 at the
time of the survey) in nearly all countries. The shift towards later
marriage is most pronounced in the Asian countries: taking the
average for eight countries shows that 57 per cent of women currently
aged 40-44 years first married before age 20; the corresponding
figure for women currently aged 20-24 years is 37 per cent. In
Africa, the reduction in the average proportion married by age 20 has
been almost as sharp - from 72 to 55 per cent - but the prevalence
of teenage marriage remains much higher than in Asia. In Latin
America and the Caribbean, changes in the timing of first marriage
have been more modest and the average proportion married before age
20, 42 per cent, is somewhat higher than in Asia
13. Age at marriage for women has also risen in the past 20 years
in the developed countries, although information on trends in age at
marriage is not comparable to that for developing countries because
most data derived from civil registration deal with legal marriage
only. In 1970, the typical average age at first marriage in Northern
and Western Europe was 22-23 years. By 1990, age at marriage in many
countries in Northern and Western Europe had risen to 25-27 years.
Increases are also observed in Northern America. In Eastern and
Southern Europe changes in marriage ages have been more modest
14. In most countries there is a general trend towards later
marriage with increased educational level. Urban-rural residence
represents a further influence on marriage ages for women. DHS data
show that women with at least 10 years of education marry between two
and seven years later than those with less than primary education.
Women living in urban areas typically marry later than their rural
counterparts although the urban-rural gap varies considerably. In
many developing countries, there is a 20 per cent or larger
difference in the proportion marrying by age 20. In others, the
difference is small
15. Differences in the age at marriage between men and women have
narrowed over time in many countries in Africa, most notably in
Northern Africa, Asia and many countries in Latin America and the
Caribbean. The convergence has been most marked in countries where
differences were the largest. In Northern America and Europe, the
gaps between the sexes have contracted further in recent decades.
16. In Europe, the upward trend in age at marriage has coincided
with an increase in the proportion cohabiting. Recent data show that
at ages 15-19, the proportions cohabiting range between nearly zero
and 20 per cent. The prevalence of cohabitation peaks at ages 20-24,
with a range of approximately 10-40 per cent, and declines
thereafter. The major reason for the decline in informal
cohabitation after age 25 is the growing dominance of legal marriage.
Cohabitation may thus be a prelude or an alternative to marriage
17. Delays in the timing of first marriage have played a key role
in the fertility decline in many countries because most births
continue to occur within marriage. Increases in the age at marriage,
however, do not necessarily translate into the shortening of the
reproductive life span. Premarital births are increasing in a number
of countries around the world. Furthermore, the prevalence of
sexually transmitted diseases among unmarried adolescents suggests
that premarital sexual activity is not uncommon and may be increasing
18. A growing body of survey data reveals wide variability in
sexual behaviour among young people. In some areas of the world
sexual activity begins early and is frequently premarital, while in
others it is dictated by strong social sanctions and commonly
coincides with marriage, although this, too, may occur at a very
early age. Despite the paucity of systematic data and the
variability in sexual behaviour of young people, some broad patterns
emerge from the evidence
19. In most areas of the world, men report an earlier age at sexual
initiation than women, a greater number of partners and a longer
period between sexual initiation and marriage. They are more likely
than women to report premarital sexual activity. Age differences
between partners have important implications for transmission of
sexually transmitted diseases. Men typically have younger female
partners, which increases the vulnerability of younger women to
sexually transmitted diseases and HIV infection. Relationships
between older men and younger women are reported to be increasingly
common in some parts of Africa
20. In the industrialized countries, there are indications of an
increase in the overall proportion of young people who are sexually
active. Age at marriage has increased; there is evidence of a fall
in the age at sexual initiation; and a greater proportion of
adolescents are involved in cohabiting relationships
21. In sub-Saharan Africa and Latin America and the Caribbean, age
at marriage has increased. Age at sexual initiation appears to have
remained unchanged, although sexual activity begins at an early age
in many countries. Increases in age at marriage, in the absence of
changes in age at sexual initiation, have meant that more young
people have been exposed to premarital sexual activity
22. Little is known about the sexual behaviour of young people in
Asia. It is typically assumed that premarital sexual activity is
uncommon and is subject to strong societal constraints. Evidence is
sparse but a few studies indicate that sexual initiation coincides
with marriage for the majority of young women, or is a prelude to
marriage. Thus, any rise in age at marriage will also increase the
age at sexual initiation
II. REPRODUCTIVE BEHAVIOUR
23. The current total fertility rate (TFR) for the world as a whole
is estimated to be 3.1 children per woman (United Nations, 1995b).
This average, however, conceals a large diversity between and within
regions. The gap between the more developed regions (TFR of 1.7) and
the less developed regions (TFR of 3.5), although narrower than in
the past, remains sizeable. The highest TFR is observed in Africa
(5.8), followed by Latin America and the Caribbean (3.1) and Asia
(3.0). At the country level, current fertility rates range from 7.6
in Yemen to 1.2 in Italy and Spain
24. During the past decade, fertility has continued its downward
trend. At the world level, the average number of children per woman
declined from 3.6 in 1980-1985 to 3.1 in 1990-1995. The underlying
change in reproductive behaviour, however, differs greatly by region.
In the more developed regions, fertility, which has been below
replacement since the late 1970s, experienced only a slight decline,
whereas in the less developed regions fertility fell from 4.2 to 3.5.
The observed reduction was more modest in the least developed
countries, where fertility declined from 6.4 to 5.8 children
25. In recent decades, adolescent child-bearing has emerged as
an issue of increasing concern throughout the developing and the
developed world. There is a growing awareness that early child-
bearing poses a health risk for the mother and the child and may
truncate a girl's educational career, threatening her economic
prospects, earning capacity and overall well-being. 26. It is
estimated that worldwide about 15 million girls aged 15-19 give birth
each year and that about 11 per cent of all babies are currently born
to adolescents (United Nations, 1995b). There is, however,
considerable variation across regions. The level of adolescent
fertility in the least developed countries (140 births per 1,000
women under age 20) is twice as high as that in developing countries
(65 births per 1,000) and four times higher than that in the
developed countries (32 births per 1,000). Within the developing
regions, adolescent fertility rates are highest in Africa (136 births
per 1,000), followed by Latin America and the Caribbean (79 births
per 1,000) and lowest in Asia (45 births per 1,000). High rates of
adolescent child-bearing are generally linked to a pattern of early
marriage
27. Although adolescent fertility is increasingly perceived as an
issue of social and policy concern, fertility rates among women under
age 20 have been falling alongside overall fertility rates worldwide,
owing to rising age at marriage, increasing educational opportunities
for young women and increased use of contraception. There are,
however, some exceptions to the overall downward trend, for example
in Haiti, India and the United States of America
28. Education has long been recognized as a crucial factor
influencing reproductive behaviour. According to a recent United
Nations study, female education is universally associated with lower
fertility (United Nations, 1995c). Countries in Latin America
display the largest fertility gaps between better educated and
uneducated women, ranging from three to five children per woman.
Fertility differentials by education are not uniform across
countries, suggesting that the resultant effect of women's education
is conditioned by socio-economic development, social structure and
cultural context. In contemporary developing societies, the impact
of individual schooling on child-bearing tends to become stronger as
the socio-economic conditions and the overall educational level of
the society improve
29. The timing of the onset of child-bearing has important
implications for individuals, families and societies. In most
countries, women's average age at first birth occurs within one and
two years after first marriage. However, marriage is not the only
context within which child-bearing takes place. In many developed
countries, the rapid increase in child-bearing outside marriage,
closely linked to the rise in cohabitation, constitutes one of the
most significant recent transformations in family-building patterns.
In the developing regions, out-of-wedlock child-bearing is relatively
rare in Asia, but commonplace in Africa and Latin America and the
Caribbean, reflecting the high prevalence of consensual unions.
30. The timing of entry into motherhood is remarkably similar across
a wide range of developing societies: it tends to occur between ages
19 and 22. In most developed countries, entry into motherhood occurs
at a later age, usually between ages 22 and 27. The trend observed
during the past decade in both developing and developed societies has
been towards a delayed pattern of family formation. The duration of
women's child-bearing span, that is, the average number of years
between women's first and last birth, is longest in Africa (ranging
from 15 to 20 years), followed by Asia (11 to 17 years) and Latin
America and the Caribbean (11 to 16 years)
31. Fertility preferences vary considerably across regions.
Desired family size is largest in sub-Saharan Africa (where it ranges
from four to eight children), followed by Asia (three to five
children), Northern Africa (three to four children) and Latin America
and the Caribbean (three to four children). The observed trend
points towards women's increasing preference for smaller families.
32. The prevailing gap between women's ideal family size and actual
child-bearing suggests that women's reproductive aspirations are
seldom fulfilled. The inadequate control women have over their
reproduction is also evident from the high prevalence of unplanned
child-bearing. The percentage of births reportedly unwanted ranges
from 2 to 26 in Africa, 6 to 21 in Asia and 5 to 35 in Latin America
and the Caribbean, and the percentage of births reportedly mistimed
ranges from 6 to 52 in Africa, 8 to 28 in Asia and 13 to 25 in Latin
America and the Caribbean
33. In the developed countries, a family with two children is the
dominant ideal and, in many cases, the preferred number of children
is above the actual total fertility rate. However, the number of
unintended births is relatively large, despite the high prevalence
of contraceptive use. In the United States, for example, 12 per cent
of all births were reported as unwanted and 27 per cent as mistimed.
34. Between 8 and 12 per cent of all couples experience some form
of infertility during their reproductive lives, a problem affecting
50-80 million people worldwide (WHO, 1991). In a small proportion
of couples (under 5 per cent) the underlying causes of infertility
are attributable to anatomical, genetic, endocrinological or
immunological factors. However, in the majority of cases, problems
of infertility arise from preventable causes, such as untreated
infection from sexually transmitted diseases, post-partum and post-
abortion complications or female genital mutilation
35. Past studies have documented unusually high incidence of
impaired fertility in Africa, particularly in Central Africa.
However, recent DHS data do not detect high levels of primary
infertility: the proportion of childless women among ever-married
women aged 40-44 does not exceed 6 per cent in any of the surveyed
countries. The prevalence of disease-induced sterility in Africa,
however, is significantly higher when secondary infertility is
examined: the proportion of women aged 30-34 subsequently infertile
is estimated to be above 20 per cent in Benin, Botswana, Cte
d'Ivoire, Ghana, Liberia, Mali, Mauritania, Nigeria, Senegal, the
Sudan, Uganda and Zimbabwe and above 30 per cent in Cameroon (Larsen,
1994)
36. A number of factors associated with the pattern of child-
bearing may adversely affect the survival and well-being of mothers
and children. Pregnancies too early or too late in the maternal life
course, high-parity pregnancies and closely spaced pregnancies are
considered to pose higher-than-normal risks to children's and women's
health. DHS data reveal that the percentage of births subject to
these risks is remarkably high, ranging from 53 to 73 in Africa, 38
to 79 in Asia and 46 to 66 in Latin America and the Caribbean. High
parity is the most common risk factor, followed by short birth
interval
37. Although changes in the age, parity and birth-spacing
distributions of fertility have the potential of reducing maternal
mortality, the majority of women who die from pregnancy, abortion or
childbirth do not fall within these high-risk categories.
Socio-economic conditions, education, nutrition and health care are
often more important determinants of women's health and survival.
Coverage of maternity services varies greatly between countries. In
15 out of 44 developing countries, the proportion of births for which
women received antenatal care was below two thirds, and in 17 out of
45 countries, less than half of the deliveries were assisted by a
trained professional
III. CONTRACEPTION
38. Family planning is an integral part of reproductive health.
Since the 1960s there has been a sustained increase in the use of
contraception in developing countries. In the early 1960s, when TFR
in the less developed regions averaged 6.1 children per woman, the
level of contraceptive prevalenceț-current use among couples with the
woman of reproductive ageț-was probably under 10 per cent in the
developing countries, while recent surveys show that contraceptive
prevalence in those regions had risen to 53 per cent by 1991. In
developed countries, contraceptive prevalence averaged 71 per cent,
and for the world as a whole the average was 57 per cent (see table
1). The level of contraceptive use in Africa, at 19 per cent, is far
below the average level for the other developing regions: 79 per
cent in Eastern Asia; 43 per cent in the remainder of Asia and
Oceania; and 59 per cent in Latin America and the Caribbean.
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Table 1. Average prevalence of specific contraceptive methods, by
region a (Percentage of couples with the woman in the reproductive
age)
Major area All Modern Sterilization Inject-
and reagion methods methods Female Male Pill able
(1) (2) (3) (4) (5) (6)
World . . . . . . . 57 49 18 4 8 1
Less developed regions 53 48 21 4 6 2
Africa . . . . . . 19 15 1 0.1 7 2
Asia and Oceania c/ 58 54 24 5 5 2
Eastern Asia c/ . 79 79 33 9 3 0.1
Other countries. . 43 36 17 2 6 3
Latin America and the 59 49 21 1 17 1
Caribbean
More developed regions d/ 71 51 8 5 17 0.1
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Vaginal
Major area barrier With- Other
area and region IUD Condom methods Rhythm drawal methods
(7) (8) (9) (10) (11) (12)
World . . . . . . . 12 5 1 3 4 1
Less developed regions 13 2 0.2 2 2 1
Africa . . . . . . 4 1 0.2 2 1 1
Asia and Oceania c/ 16 2 0.2 2 2 0.3
Eastern Asia c/ . 31 2 0.3 0.4 0.1 --
Other countries. . 5 3 0.1 3 3 1
Latin America and the 6 2 1 6 3 0.5
Caribbean
More developed regionsd 5 14 2 6 12 1
Source: World Population Monitoring, 1996 (United Nations
publication, forthcoming).
Note: These estimates reflect assumptions about contraceptive use
in countries with no available data.
a/ Based on the most recently available survey data: average date, 1991.
b/ Including methods in columns 3-9.
c/ Excluding Japan.
d/ Australia-New Zealand, Europe, Northern America and Japan.
------------------------------------------------------------------------------
39. The transformation in contraceptive practice reflects the
growing desire of couples and individuals to have smaller families
and to choose when to have their children. It also reflects the
great increases in the availability of effective modern
contraceptives in developing countries and of associated family
planning information and services. Although the recent changes in
the developed regions concern primarily the choice of specific birth
control methods rather than the overall level of contraceptive use,
the introduction of modern methods has also brought about a
transformation in contraceptive practice.
40. Most users of contraception are women and most of them use
modern methods. Relative ly effective clinic and supply ("modern")
methods account for an estimated 87 per cent of contraceptive use
worldwide. The three main "female" methodsț-female sterilization,
intra-uterine devices (IUDs) and oral pillsț-account for over two
thirds of contraceptive practice worldwide, and three fourths of use
in the less developed regions. Modern methods in general make up a
larger fraction of contraceptive use in the developing than in the
developed countries, estimated at 91 and 73 per cent, respectively.
Prevalence of clinic and supply methods averages 51 per cent in the
more developed regions and 48 per cent in the less developed regions.
The prevalence of non-supply and traditional methods differs more
between the developed and the developing countries, 20 and 5 per
cent, respectively. This group of methods includes periodic
abstinence or rhythm, withdrawal (coitus interruptus), abstinence,
douching and various folk methods. The higher levels of use of these
methods in the developed countries reflects the continuing influence
of patterns of fertility control established before the era of modern
contraceptive methods and also the lack of wide availability of newer
methods in some countries. Some developed countries where the use
of traditional methods was widespread around 1970 have undergone a
marked transition to the use of modern methods: Belgium, France and
Hungary are examples. However, some countries in Eastern Europe with
surveys conducted in the 1990s still show high prevalence levels of
traditional methods: examples include the Czech Republic, Romania
and Slovakia.
41. Most developing countries with available trend data show a
substantial recent increase in contraceptive use. Consideration of
trends between the most recent available survey and surveys conducted
about 10 years earlier, shows that increases in contraceptive use
have been the most rapid in countries that had a moderate level of
use at the start of the period. Where prevalence was in the range
of 15-50 per cent, the level of contraceptive use subsequently grew
by more than 1.0 per cent per annum in over 80 per cent of the
countries. By contrast, annual increases of 1.0 points or more
occurred in about 55 per cent of the developing countries where
prevalence was initially either below 15 per cent or above 50 per
cent. Although the average level of contraceptive use remains much
lower in Africa than in other developing regions, surveys conducted
in the past few years have continued to add to the evidence of
increasing use of contraception in continental sub- Saharan Africa.
42. With respect to the use of particular types of contraception,
rising use of female sterilization is the most important trend in
both developed and developing countries. None the less, there are
many individual countries where other methods are responsible for
most of the recent trend. While there is a general tendency for
modern methods as a group to become more predominant over time, there
is little sign that the widely varying national patterns of use are
converging to the same method mix. Only rarely does a single type
of contraception account for most of current use.
43. Recent surveys indicate a significant rise in the level of use
of condoms in several countries, suggesting that campaigns promoting
this method are having an effect. On average, condoms account for
only about 8 per cent of contraceptive practice reported by married
women. However, men tend to report more use of this method than do
women. Levels of condom use among unmarried men are usually higher
than among married men, even though the general level of
contraceptive use is higher among the married men.
44.Despite the recent rapid growth in the use of contraception, a
variety of indicators suggest that the level of unmet need remains
high, with about 20-25 per cent of couples in developing countries
(except China) at risk of an unwanted or mistimed pregnancy, but not
using contraception. In Africa and in some countries in other
regions, substantial proportions of the population still have no
knowledge of any type of contraception. Furthermore, the percentage
of women who know of a place to obtain family planning information
or services is sometimes much lower than the percentage of those who
have heard of a method. In Asia and Northern Africa, 90 per cent or
more of women knew of a service outlet in over three fourths of the
countries with available data, and in Latin America and the Caribbean
this level was reached in about 60 per cent of countries. However,
this level of knowledge of services was observed in only 2 of 23
countries in sub-Saharan Africa (Botswana and Zimbabwe).
45. In general, problems of limited knowledge of and access to
family planning reflect the difficulty many Governments have
experienced in extending services nationwide rather than a deliberate
policy to restrict access. By 1995, only two Governments (out of
190) had an official policy of limiting access to modern
contraceptive methods, while 82 per cent of the Governments provided
direct support for family planning services. Ratings of various
aspects of family planning policy and programme performance carried
out in 1982, 1989 and 1994 indicate that there was rapid growth in
programme effort and method availability during the 1980s. A further
increase was noted in many countries since 1989, but at a slower pace
than between 1982 and 1989. Based on knowledgeable observers'
ratings of the availability of five types of contraception, in 1994
condoms were estimated to be readily available to about two thirds
of the population of developing countries, and oral pills, IUDs and
female sterilization to about 60-65 per cent. Male sterilization was
judged to be readily available to slightly less than 50 per cent of
the population. Despite substantial recent improvements,
contraceptive methods are much less readily available in sub-Saharan
Africa than in other regions.
46. In most developing countries levels of contraceptive use are
substantially higher among urban and well-educated women than among
their rural and less educated counterparts. During the past 10-15
years, the average size of the social differentials in contraceptive
practice has changed very little, although this is partially due to
offsetting changes in different countries. Where contraceptive use
had been low to start with, differentials usually widened, and the
reverse was true in countries where use levels were already high at
the earlier date in urban areas or among highly educated women.
47. Many surveys have limited questions about current contraceptive
use to married women. Recently, more surveys have posed these
questions to unmarried women, and these data show that an exclusive
focus on married women leaves out a significant proportion of
contraceptive users in many cases. In sub-Saharan Africa and in the
more developed regions with such information available, women not in
a union make up about one fourth of all contraceptive users, on
average, and in Latin America and the Caribbean nearly 10 per cent.
48. While some couples use a single contraceptive method
successfully for many years, most are likely to stop contraceptive
use or switch from their first method at some point. Studies of
contraceptive discontinuation show that within a year of starting to
use the pill, typically 40-60 per cent of women will have stopped,
15-30 per cent for IUD, more than 50 per cent for the condom and
about 40-60 per cent for periodic abstinence (including thecalendar
rhythm method). Reasons for stopping vary by method. In general,
methods that are highly effective at preventing pregnancy have a high
incidence of side-effects and vice versa.
49. Side-effects and worries about them stand out consistently
in studies of different populations as one of women's major concerns
about modern contraceptive methods. Health concerns and side-
effects are frequently cited as the reason for discontinuing the
methods, and in many cases a substantial proportion of women who are
at risk of an unwanted pregnancy report that health concerns are
their main reason for not using contraception. At the same time, the
recent rise in the level of contraceptive use is due almost entirely
to increased use of modern methods. The evidence suggests that,
although modern methods have worked well for many couples, their use
still presents difficult choices for many others. The rapidly
increasing reliance on the permanent method of surgical sterilization
must be in part a reflection of the drawbacks of the temporary
methods and services that are currently available.
50. Although most information about contraceptive use and unmet
need is derived from surveys of women, recently more surveys have
asked men about these topics. This information is only now beginning
to be analysed in detail. In some countries a substantial proportion
of the women with an apparent unmet need for contraception report
that they are not using any method because of opposition from their
spouse, which could refer either to opposition to contraception in
general or to a disagreement about the number and timing of children.
The available evidence about disagreements between spouses points to
a variety of situations whose relative importance is often impossible
to quantify. Some men clearly do expect to make the choice about
using contraception (even if it is the woman who uses the method),
while others view this as being completely the woman's
responsibility. In some countries, many people do not know their
partner's views about family planning. The question of how
inter-spouse disagreements are resolved in practice deserves more
attention than it has received to date, and this requires obtaining
comparable information from both men and women.
IV. ABORTION
51. Approximately 25 million legal abortions were performed
worldwide around 1990, or one legal abortion for every six births.
This estimate must be considered the minimum number of legal
abortions, as no attempt has been made to estimate the magnitude of
unreported legal abortions. Given the clandestine nature of unsafe
abortion, its incidence is very difficult to gauge. WHO has
estimated that some 20 million unsafe abortions are performed each
year, or one unsafe abortion for every seven births (WHO, 1994).
Thus, at a minimum, some 45 million abortions a year are thought to
be taking place globally, that is, nearly one abortion for every
three live births.
52. Induced abortion has attained high public visibility in many
countries, both developed and developing. In some cases, public
concern has been voiced primarily because of the alarmingly high
levels of maternal mortality and morbidity that have resulted from
unsafe abortion. In others, the visibility has resulted more from
public debate concerning the moral and legal status of abortion and
the role that the State should play in permitting or denying access
to induced abortion.
53. At the International Conference on Population and Development
in 1994, the issue of abortion proved to be one of the most
contentious, with much of the debate dealing directly or indirectly
with various abortion-related issues. At the end of the debate,
delegations agreed on the following wording: "In no case should
abortion be promoted as a method of family planning. All Governments
and relevant intergovernmental and non-governmental organizations are
urged to strengthen their commitment to women's health, to deal with
the health impact of unsafe abortion 1/ as a major public health
concern and to reduce the recourse to abortion through expanded and
improved family planning services...." (United Nations, 1995a, chap.
I, resolution 1, annex, para. 8.25).
54. Induced abortion is one of the oldest methods of fertility
control and one of the most widely used (United Nations, 1992, 1993
and 1995d). It is practised both in remote rural societies and in
large modern urban centres and in all regions of the world, although
with differing consequences. In countries where abortion is legal
and widely available, abortions generally pose a relatively small
threat to women's reproductive health. Where abortion is illegal,
however, it is usually performed in medically substandard and
unsanitary conditions, leading to a high incidence of complications
and resulting in chronic morbidity and often death. Indeed, WHO has
estimated that more than 70,000 women die annually as a result of
complications arising from unsafe abortion. Moreover, long-term
consequences of unsafe abortion may include chronic pelvic pain,
pelvic inflammatory disease, tubal occlusion, secondary infertility
and increased risk of spontaneous abortion in subsequent pregnancies
(WHO, 1994).
55. Substantial variations exist in incidence of unsafe abortion
by region. The incidence of unsafe abortion varies from a high of
30 or more unsafe abortions per 1,000 women aged 15-49 years in
Eastern and Western Africa, Latin America and the Caribbean and the
former USSR to fewer than 2 unsafe abortions per 1,000 women aged
15-49 years in Northern Europe and Northern America (WHO, 1994).
Some of the variations in the incidence of unsafe abortion can be
explained by the less restrictive nature of abortion laws in Northern
Europe and Northern America (11 of 12 countries permit abortion on
request or for economic or social reasons), as compared with Eastern
and Western Africa and Latin America and the Caribbean (2 of 45
countries permit abortion on request or for economic or social
reasons). Lack of legal restrictions on abortion, however, does not
necessarily guarantee access to safe abortion, as evidenced by the
relatively high incidence of unsafe abortion in the former USSR
(estimated by WHO at 30 unsafe abortions per 1,000 women aged 15-49
years), despite the availability of abortion on request since 1956.
56. In line with the heightened interest in adolescent reproductive
behaviour, adolescent abortion is a growing area of concern. Because
adolescents are sometimes unwilling or unable to seek appropriate
health care or wait longer in the gestation period to obtain help,
induced abortion generally presents a greater risk to the health and
life of the adolescent than to an adult woman. According to recent
United Nations estimates, abortion among adolescents has accounted
for 15-25 per cent of total reported legal abortions in a number of
developed and developing countries.
57. Based on information available for 193 countries, the
overwhelming majority of countries (98 per cent) permit abortions to
be performed to save the pregnant woman's life (United Nations, 1992,
1993 and 1995d). In a number of those countries, criminal laws
specifically allow abortion on this ground. In others, however, one
must look to other laws or court decisions to determine if there are
exceptions to a general prohibition of abortions. For example, in
Honduras, the Code of Medical Ethics permits abortion to save the
woman's life; in Nepal, the rules of the Medical Council have been
interpreted to permit abortion in various situations; and in Ireland
the Supreme Court has ruled that an abortion can be performed to
preserve the life of the pregnant woman. In yet other countries, the
criminal law principle of necessity can be invoked to exempt from
punishment the performance of an abortion to save a pregnant woman's
life. Examples include the Central African Republic, the Dominican
Republic, Egypt and the Philippines.
58. Abortion to preserve the woman's physical health is permitted
in 119 countries (62 per cent). Fewer countries (95, or 50 per cent)
allow abortion to preserve the woman's mental health, and 81
countries (42 per cent) permit it when pregnancy has resulted from
rape or incest. The number declines to 78 countries (40 per cent)
when there is the possibility of foetal impairment and to 55
countries (29 per cent) when there are economic or social reasons.
Finally, in 41 countries (21 per cent), abortion is available on
request.
59. An examination of abortion policies in terms of population
discloses that 96 per cent of the world population live in countries
that permit abortion to save the woman's life, 75 per cent live in
countries permitting abortion to preserve the woman's physical
health, 69 per cent in countries where abortion is legal to preserve
the woman's mental health and 72 per cent in countries where abortion
is allowed when the pregnancy results from rape or incest. The
percentage declines to 64 when there is the possibility of foetal
impairment and to 44 in countries that permit abortion for economic
or social reasons. Finally, abortion is available on request to 38
per cent of the world population.
V. MATERNAL MORTALITY AND MORBIDITY
60. Among the health and mortality indicators, levels of mortality
show striking disparities according to levels of development.
Maternal mortality is a sensitive indicator of the status of women
in society, their access to health care and the adequacy of the
health care system in responding to their needs. Information about
levels and trends of maternal mortality is needed, therefore, not
only to assess the risks of pregnancy and childbirth, but also for
what it implies about women's health in general and, by extension,
their social and economic well-being.
61. It is extremely difficult to assess levels of maternal
mortality at the national level. Doing so requires knowledge about
deaths of women of reproductive age (15-49 years), the cause of death
and also whether or not the woman was pregnant at the time of death
or had recently been so. Yet, few countries register all births and
deaths; even fewer register the cause of death; and fewer still
systematically note pregnancy status on the death form.
62. Inevitably, countries with the least developed systems of vital
registration are those with the worst health indicators. In such
circumstances, alternative ways have to be developed for estimating
levels of maternal mortality. A variety of innovative methodologies
have been devised to overcome the absence of data in countries with
poor or non-existent vital registration. For example, maternal
mortality can be measured by incorporating questions on pregnancy and
deaths into large-scale household inquiries, but this approach
requires a large sample size and is expensive and time-consuming.
A more cost-effective approach is the "sisterhood method", which adds
on to existing household surveys a few simple questions about whether
or not the sisters of the respondent are still alive. Much smaller
sample sizes are needed because each respondent can provide
information on a number of sisters. However, the results do not
provide current estimates but give an idea of the levels of maternal
mortality roughly 10 years earlier.
63. The best way to measure maternal mortality in the absence of
vital registration is to identify and investigate the causes of all
deaths of women of reproductive age - the Reproductive Age Mortality
Survey (RAMOS). Multiple sources of information - civil registers,
health facility records, community leaders, religious authorities,
undertakers, cemetery officials, schoolchildren - must be used to
identify all deaths. Subsequently, interviews with household
members, health-care providers and facility records are used to
classify deaths as maternal or otherwise (verbal autopsy). Although
RAMOS studies are considered to be the "gold standard" for estimating
maternal mortality, they are also time-consuming and complex to
undertake, particularly on a large scale.
64. Because of the difficulties and costs involved, only nine
developing countries have carried out RAMOS or household studies to
estimate maternal morality at the national level. In such
circumstances, other methods have to be devised to provide broad
estimates of the extent of the problem. WHO and UNICEF have
developed new estimates of maternal mortality using a simple
modelling strategy. This is based on existing data sets and uses two
independent variables - general fertility rates and proportion of
births that are assisted by a trained person -to predict values for
countries with no sound national estimate of maternal mortality.
65. The model is primarily intended to be of use in countries with
no estimates of maternal mortality or where there is concern about
the adequacy of officially reported estimates. It provides figures
on orders of magnitude rather than precise estimates of maternal
mortality. The standard errors associated with the predicted
maternal mortality ratios are very large. Moreover, the ratios
generated from the modelling exercise cover a 10-year time span
(roughly 1982-1992). They cannot, therefore, be used for regular
monitoring of trends. The figures pertain to around 1990 and should
be seen as a recalculation of the earlier 1991 revision prepared by
WHO rather than as indicative of trends since then.
66. Preliminary results of the new model are shown in table 2.
The results indicate that maternal mortality is higher than
previously estimated, with some 590,000 maternal deaths compared with
509,000, according to the earlier model. The most significant
differences between the old and the new model are for Africa, where
the maternal mortality ratio according to the new estimates is 878
per 100,000 live births, compared with the earlier estimate of 630
per 100,000. By contrast, the estimates produced by the new model
for Asia and Latin America and the Caribbean show relatively small
changes compared with the earlier model.
=========================================================================
Table 2. Estimates of maternal deaths and maternal mortality
ratios, 1990
Maternal deaths
Major area Number Ratio
and region thousands) (per 100,000 live births)
World. . . . . . . . . . 590 429
More developed regions . 4 27
Less developed regions . 586 479
Africa . . . . . . . . . 238 878
Asia . . . . . . . . . . 323 383
Europe . . . . . . . . . 3.2 36
Latin America and the Caribbean 23 194
Northern America . . . . 0.5 11
Oceania. . . . . . . . . 2.0 382
Source: World Health Organization, Maternal Mortality Ratios and
Rates: A Tabulation of Available Information, 4th ed. (Geneva,
forthcoming).
==========================================================================
67. If counting the total numbers of maternal deaths is difficult,
estimating the causes of those deaths is even more so. Few studies
collect information on the cause of death in a standard format or
follow the categories of causes of death described in the
International Classification of Diseases. However, based on the
evidence of the few good community-based studies, it is possible to
estimate the breakdown of maternal mortality by five major causes of
death. A summary of the incidence of and mortality from the five
major obstetric complications is given in table 3. There are
significant regional variations within these
=========================================================================
Table 3. Estimated global incidence and mortality from main
obstetric complications worldwide, 1990
Number of Number Percentage
Obstetric cases a/ of deaths of all maternal
complications (thousands)(thousands) deaths
Haemorrhage 14 300 150 25
Sepsis 12 000 90 15
Hypertensive disorders of 7 100 75 13
pregnancy and eclampsia
Obstructed labour 7 300 40 7
Unsafe abortion 19 900 75 13
Other direct causes 3 600 50 8
Indirect causes 13 500 110 19
Total 77 600 590 100
Source: World Health Organization, Maternal Health and Safe
Motherhood Programme (Geneva), unpublished estimates.
a/Estimated number of events, not women.
=========================================================================
these global totals. Abortion is likely to account for a larger
percentage of overall maternal mortality in Latin America although
the maternal mortality ratio is generally lower in that region than
in most parts of Africa.
68.In these calculations it has been assumed that each complication
is a discrete event and, therefore, that complications arise in some
56 per cent of pregnancies ending in live birth. The severity of the
complication will, of course, vary and WHO estimates that almost 15
per cent of all women develop complications serious enough to require
rapid and skilled intervention if the woman is to survive without
lifelong disabilities. Such disabilities include obstetric fistula
(damage to the bladder and/or rectum); reproductive tract infections;
pelvic inflammatory disease; infertility; anaemia; prolapse; and
damage to the brain, kidneys and cardiovascular system.
=====================================================================
Table 4. Effect of pregnancy complications on mother and baby
---------------------------------------------------------------------
Problem or Most serious effects on Most serious effects
compilation mother's health on new born
baby-foetus
---------------------------------------------------------------------
Severe anaemia Cardiac failure Low birth weight, asphyxia,
stillbirth
Haemorrhage Shock, cardiac failure, Asphyxia,
infection stillbirth
Hypertensive disorders Eclampsia, Low birth weight,
of pregnancy cerebrovascular accidents asphyxia,
stillbirth
Puerperal sepsis Septicaemia, shock Neonatal sepsis
Obstructed labour Fistulae, uterine Stillbirth,
rupture, prolapse asphyxia,
amnionitis, sepsis sepsis,
birth trauma,
handicap
Infection during Premature onset of labour, Premature
pregnancy, sexually ectopic pregnancy, pelvic delivery,
transmitted diseases inflammatory neonatal
disease, infertility eye infection,
blindness
pneumonia,
stillbirth,
congenital
syphilis
Hepatitis Postpartum haemorrhage, Hepatitis
liver failure
Malaria Severe anaemia, cerebral Prematurity,
thrombosis intra-uterine
growth
retardation
Unwanted pregnancy Unsafe abortion, infection, Increased risk
pelvic inflammatory of morbidity,
disease, infertility mortality;
child abuse,
neglect,
abandonment
Unclean delivery Infection, maternal Neonatal tetanus,
tetanus sepsis
===========================================================================
69. The complications that cause the deaths and disabilities of
mothers also damage the infants they are carrying (see table 4). Of
the approximately 8 million infant deaths each year, almost two
thirds occur during the neonatal period, before the baby is one month
old. Every year there are 5 million neonatal deaths, of which 3.5
million occur within the first week of life and are largely a
consequence of inadequate or inappropriate care during pregnancy,
delivery or the first critical hours after birth. And for every
newborn death another infant is stillborn.
70. Aside from considerations of the numbers of deaths and
disabilities, there is also the issue of the nature of a maternal
death. The mothers who die are in the prime of life, at the summit
of their social and economic productivity. They leave behind them
families, many with young children, who must survive without the
support of the prime caregiver, producer of food and generator of
income.
71. The paucity of information about maternal ill-health has
resulted in long neglect of the problem, neglect that the
international community has only recently started to address. There
is still much that has to be learned, not about the interventions
needed to reduce maternal deaths, which have been known for many
years, but about how to implement those interventions in a
sustainable way in resource-limited settings. Although maternal
mortality and morbidity are major components of reproductive
ill-health, addressing them requires interventions that differ, in
several important ways, from the interventions needed to deal with
other components of reproductive ill-health. In particular, it will
not be possible to achieve sustainable reductions in maternal
mortality in the absence of functioning district health systems,
including widespread availability of maternal health care at the
community level along with appropriate referral and management of
complications and emergencies.
VI. SEXUALLY TRANSMITTED DISEASES, INCLUDING HIV/AIDS
72. Until recently, the prevention and control of sexually
transmitted diseases was a low priority for most countries and
development agencies. Lack of awareness of the problem of sexually
transmitted diseases and their complications and sequelae,
competition for resources to control other important health problems
and reluctance of public health policy makers to deal with diseases
associated with sexual behaviour have all played a role in this
neglect.
73. To date, most programmes for the prevention of sexually
transmitted diseases have focused on prevention of complications
(secondary prevention). The prevention of transmission of infection
(primary prevention) is at present receiving increased attention
because of the global HIV/AIDS epidemic and the identification of
several sexually transmitted diseases as risk factors for the spread
of HIV.
74. Currently in its second decade, the HIV epidemic continues to
grow with thousands of new infections occurring every day. An
estimated cumulative total of 18.5 million adults and 1.5 million
children have been infected with HIV. Of all the infected cases, 7-8
million are women, about 70 per cent of whom are of child- bearing
age. According to WHO, between 13 million and 15 million infected
adolescents and adults, in addition to about half a million infected
children, are alive today.
75. The longer term dimensions of the HIV/AIDS pandemic cannot yet
be forecast with confidence. However, on the basis of the available
data on the current global status of the pandemic and recent trends
in its spread, WHO has generated a plausible range of projected new
HIV infections during the 1990s. In making projections of the future
magnitude of the pandemic, WHO uses the lower limit of its estimated
range of the HIV prevalence for each region. The results should thus
be considered conservative.
76. During the current decade, WHO forecasts that about 10-15
million new cases of HIV infections may be expected in adults, mostly
in developing countries. During the same period, WHO projects that
as many as 5-10 million children will be HIV-infected through their
mothers, the majority of them in sub-Saharan Africa. By the year
2000, 30-40 million HIV infections will have occurred, 90 per cent
of which will be in developing countries. The projected cumulative
total number of HIV-related deaths is predicted to rise to more than
8 million from its current total of 2 million. WHO also estimates
that over 5 million children under age 10 years will be orphaned by
the end of the 1990s as a result of the HIV-related deaths of their
parents. The number of orphans will increase further in the early
years of the twenty-first century as a result of the death of those
mothers who were infected with HIV in the 1990s.
77. The epidemic is having devastating effects on individuals,
families and entire communities. For women, HIV infection has added
its burden to risks related to sexually transmitted diseases,
pregnancy and childbirth. The proportion of women with HIV and AIDS
has increased, especially in developing countries. Young people are
particularly affected by HIV and AIDS. It is estimated that 50 per
cent of HIV infections occur in age group 15-24. This has an
important impact on the economy of many countries since the age
groups most affected - young and middle-aged adults - constitutes the
bulk of the workforce. The socio-economic burden of sexually
transmitted diseases, in terms of direct and indirect costs, is
increasing rapidly.
78. Over the past 10 years, the response to HIV/AIDS has focused
on prevention, as well as on care. Governments, non-governmental
organizations, communities, associations and networks of people
living with HIV/AIDS, international organizations and the health,
education and other sectors, as well as the public and private
sectors, have worked in partnership to develop a response to the
epidemic.
79. The epidemiological trends of sexually transmitted diseases in
various parts of the world are strikingly different. In the
developing countries the epidemic is characterized by high incidence
and prevalence; a high rate of complications; an alarming problem of
anti-microbial resistance; and the interaction with HIV infection.
It is estimated that about 333 million curable cases of sexually
transmitted diseases occur globally every year, most of which are
occurring in developing countries.
80. Sexually transmitted diseases have been a neglected area in
public health in most of the developing countries despite the
overwhelming facts of their impact on health, particularly for women
and newborns. For several decades, sexually transmitted diseases
have ranked among the top five conditions for which adults in many
developing countries seek health-care services. In most
industrialized countries, on the other hand, there has been a
spectacular decline in the incidence of sexually transmitted
diseases, particularly gonorrhoea and syphilis.
81. Chlamydia infection is by far the most common bacterial
sexually transmitted disease in Europe. For some time its incidence
had been seriously underestimated because of a lack of diagnostic
facilities. In countries with an active chlamydia control policy,
there has been a well-documented reduction in the number of cases,
particularly in women.
82. Reliable data on the incidence of sexually transmitted diseases
in developing countries are scarce, although prevalence surveys have
been conducted in many countries, particularly in Africa. In
general, the survey data show higher rates of gonorrhoea, syphilis
and chlamydia than in comparable populations in Europe or Northern
America. However, there is also a large variation in prevalence,
with some populations having low levels of infection. It should be
stressed that the prevalence rate of a bacterial sexually transmitted
disease is the result of both sexual exposure of the population and
the proportion of infections adequately treated.
83. Women, especially young women, are more vulnerable than men to
infection with a sexually transmitted disease and its complications
(such as infertility, cancer and inflammatory diseases). The high
prevalence of sexually transmitted diseases among women attending
antenatal, family planning or gynaecological clinics in developing
countries provides an indication of the extent of the problem of
sexually transmitted diseases. For example, in studies in developing
countries, up to 19 per cent of the pregnant women have been found
to have gonorrhoea or chlamydia, up to 20 per cent to have syphilis.
84. Biologically women are more susceptible to most sexually
transmitted diseases than men, at least in part because of the
greater mucosal surface exposed to a greater quantity of pathogens
during sexual intercourse. Women with a sexually transmitted disease
are more likely than men to be asymptomatic, and, therefore, are less
likely to seek treatment, resulting in chronic infections with more
long-term complications and sequelae.
85. There are important overlaps between programmes for the
prevention of HIV/AIDS and sexually transmitted diseases and care
programmes and other components of reproductive health programmes.
Family planning services and maternal health/antenatal care services
offer an important opportunity for both diagnosis and treatment of
sexually transmitted diseases, as well as information about their
prevention, including safer sexual behaviour and related services
such as the provision of condoms.
VII. REPRODUCTIVE RIGHTS
86. Reproductive health and rights are relatively new subjects in
the area of population policy. Reproductive health and rights are
also a particularly controversial topic. They relate to areas of
life that are the most intimate and personal such as sexuality,
sexual relations and reproduction, as well as to matters that are
central to how the members of a family relate to one another and how
they perceive themselves. They are also linked with the status of
women and the empowerment of women, matters which, themselves,
provoke controversy in many countries.
87. Reproductive rights may be viewed as certain rights that all
persons possess that will allow them access to the full range of
reproductive health care. In particular, as formulated at the past
three international conferences on population and at the Fourth World
Conference on Women, these rights include the right of all couples
and individuals to decide freely and responsibly the number, spacing
and timing of their children and to have the information and means
to do so. They also include the right to attain the highest standard
of sexual and reproductive health and the right to make reproductive
decisions free from discrimination, violence and coercion.
Furthermore, the Programme of Action of the International Conference
on Population and Development and the Platform for Action of the
Fourth World Conference on Women make clear that all of these rights
are grounded in national laws, international human rights instruments
and other international consensus documents.
88. Although the concept of reproductive rights is of relatively
recent origin, there is ample support for those rights in existing
international documents and human rights treaties. For example, the
final documents adopted at all three international conferences on
population as well as at the Fourth World Conference on Women
strongly assert reproductive rights. Drawing on the language
originally formulated at the International Conference on Human
Rights, held at Tehran in 1968, each document provides that all
couples and individuals have the right to decide freely and
responsibly the number and spacing of their children and the
information, education and means to do so. While the documents are
not legally binding in terms of international law, they do bear great
normative authority and have been endorsed by the vast majority of
Governments.
89. Formal international treaties that are legally binding also
support the concept of reproductive rights, if not by name. For
example, the International Covenant on Civil and Political Rights
(the Political Covenant), contains a number of provisions that are
relevant to the right to make voluntary decisions about bearing
children. Similarly, the International Covenant on Economic, Social
and Cultural Rights (the Economic Covenant)--the sister treaty to the
Political Covenant--recognizes the right of persons to enjoy the
highest standards of health and calls for special attention to be
given to women before and after childbirth and to the reduction of
infant mortality. With the approval of the Convention on the
Elimination of All Forms of Discrimination against Women (the Women's
Convention) in 1979, these reproductive rights are made explicit and
strongly endorsed. National laws also support reproductive rights,
with laws relating to maternal/child health care, access to the
various forms of family planning, sex education and treatment and
prevention of sexually transmitted diseases being common in both
developing and developed countries.
90. One of the cornerstones of the concept of reproductive rights
is the right of access to methods of family planning. This idea has
been fundamental to definitions of reproductive rights from the
beginning, appearing repeatedly in population and human rights
documents as the right to have the "information and means" to decide
freely and responsibly on the number and spacing of children.
Without such access, reproductive rights have, practically speaking,
no real meaning.
91. Adolescent reproductive behaviour has become an emerging
worldwide concern. Most countries do not have coherent policies for
the protection and maintenance of reproductive health in adolescents,
partly because of the sensitivity of the subject. Several key issues
concerning the reproductive rights of adolescents pertain to
marriage. In many parts of the world, women's basic human rights are
violated when they are given in marriage without their consent.
Moreover, despite legislation designed to eliminate the practice,
girls in many countries marry shortly after puberty and are expected
to start having children almost immediately, in part because of a
lack of alternative opportunities. The problems of early
child-bearing are not only biomedical, but also result in reduced
educational and economic opportunities for young mothers.
92. Many obstacles exist in the achievement of the goals of
reproductive rights and reproductive health. Because of the
sensitive and controversial character of the issues involved--in
particular, sexuality, contraception, the empowerment of women and
family relationsț-there is resistance to the expansion of
reproductive rights. Another major problem is conceptual in nature.
In many countries, human and reproductive rights, as expressed in
international documents, are not familiar to the general public and
little information is disseminated on those rights. In addition,
human and reproductive rights may seem abstract in their formulation
or even foreign to local experiences, attitudes and traditions. The
less educated are especially likely to lack knowledge about their
rights. Also, women more than men are subject to restrictions on
their personal status that prevent them from obtaining information
on their rights. Thus, many women are not aware that they have
reproductive rights; without such awareness they are unlikely to
exercise those rights.
93. In the light of these obstacles, action to achieve reproductive
rights and health is restricted in scope. One strategy to overcome
such obstacles is to try to strengthen and make greater use of
international treaty enforcement and monitoring mechanisms. Another
strategy is to increase the provision of information and education
on reproductive rights and reproductive health. Efforts can be
increased to reach the millions of persons throughout the world who
have little knowledge or understanding of reproductive health. These
efforts can include furnishing basic facts on health and the
reproductive system, as well as information on how reproductive
health is closely connected to such matters as the age of marriage,
education, the status of women and harmful practices such as female
genital mutilation. Publicity can also be given to the existence at
the international level of documents that countries have ratified
which support rights in these matters, particularly the right to
decide freely and responsibly on the number and spacing of children.
Moreover, to be effective, provision of this information should be
provided to medical personnel, religious leaders, government
officials and non- governmental organizations.
94. Of critical importance is presenting the concept of
reproductive rights in ways that are appropriate at the local level.
One approach is to point to local laws that themselves support
reproductive rights, such as the constitutions, population policies
and health laws of various countries. Another is to draw on local
social movements and traditions that support reproductive rights.
A third approach is to relate "rights" language to the actual needs
at the local level, needs for basic health services, family planning
and education, for example. For the concepts of reproductive rights
and reproductive health to be implemented at the local level, they
need be integrated into existing social, political and religious
structures and thus become part of the complex fabric of society.
VIII. POPULATION INFORMATION, EDUCATION AND COMMUNICATION
95. In the field of population, the term information, education and
communication is used as the strategic combination of all three
processes in efforts to provide information on services, create
public awareness and advocate for action on population and
development issues. The term information, education and
communication programme interventions is usually conceived as an
integral part of a country development programme, which aims at
achieving measurable behaviour and attitude changes of specific
audiences, based on a study of their needs and perceptions.
96. The implementation of the Programme of Action of the
International Conference on Population and Development requires
political support and advocacy, understood here as a full commitment
to its principles, goals and objectives. Effective advocacy is
essential in creating awareness of reproductive rights and
reproductive health and can be facilitated by the use of effective
information, education and communication strategies. The importance
of information, education and communication in the area of
reproductive rights and reproductive health derives from the
recognition that they are important instruments that stimulate
attitudinal and behavioural changes. In the area of human
reproduction and health, various strategies have been used in
attempts to develop positive attitudes and encourage responsible and
healthy behaviour, help increase community participation in
population activities and facilitate acceptance of population
programmes in diverse cultural settings.
97. A primary aim of information, education and communication
activities should be to motivate policy makers, programme managers,
service providers and communities to translate into action the
concept of reproductive rights and reproductive health, including
family planning. This will require the strengthening of national
capacities to undertake appropriate information, education and
communication activities. It will also require that information,
education and communication messages be effective and that service-
delivery systems respond to the increased demand that those messages
contribute to generating.
98. There is a large variety of information, education and
communication programmes that combine strategies of mass, group and
one-to-one communication approaches and that use different channels,
from interpersonal and peer support to formal school curricula, from
traditional and folk media to mass entertainment and news media, and
production and dissemination of specific materials. The spectrum of
activities includes a large array of operations that covers
awareness-raising campaigns, art exhibits, painting and poster
competitions; design, development and distribution of information,
education and communication and training materials; printing and
distribution of booklets, brochures and comic books with family
planning, sexual health and HIV/AIDS prevention messages; radio and
television programmes, particularly soap operas with family planning
and HIV/AIDS themes; dramas and puppet shows; seminars and workshops;
telephone hot lines; and preventive counselling, including the
distribution of condoms. When planned in a coordinated and strategic
manner, these activities can make a significant contribution to the
impact of population programmes.
99. Three key issues have been identified in population
information, education and communication programmes. First, social,
cultural and political conditions can affect the recognition of
reproductive rights and may limit access to reproductive health
services and information; myths and ignorance may constitute major
obstacles. Secondly, information, education and communication
activities are not always properly linked to the delivery of
reproductive health and family planning information and services.
And thirdly, there is a need for adequate indicators for measuring
progress in this field.
100. Population policies and legislation have a major role to play
in the creation of a supportive environment for reproductive health
and family planning. Information, education and communication
activities are facilitated when they are supported by population
policies and appropriate legislation. It is also recognized that
information, education and communication activities are valuable
instruments for facilitating the understanding and acceptance of the
goals and objectives of population policies.
101. Reproductive health and family planning programmes are
usually a major component of national population policies and
strategies, and information, education and communication activities
provide strong programme support. Strengthening their links will
make them mutually supportive and thus enable national programmes to
better satisfy unmet demands through the delivery of high-quality
reproductive health and family planning services. Many of these
programmes include also the prevention and control of sexually
transmitted diseases and HIV/AIDS and information, education and
communication activities that are valuable tools in reaching groups
at risk, especially adolescents, and in raising awareness and
promoting behavioural change.
102. Population education is another common strategy adopted by
Governments as part of their population policies. Population
education programmes usually cover topics that range from population
dynamics to pregnancy and family planning, family life, sex education
and, more recently, new ways of looking at gender issues, and
HIV/AIDS and sexually transmitted diseases. There is increasing
evidence that sex and HIV/AIDS education programmes may reduce unsafe
practices among sexually active adolescents and reduce early
pregnancies.
103. The Programme of Action of the International Conference on
Population and Development calls for a coordinated strategic approach
to information, education and communication that should be linked to,
and complement, national population and development policies and
strategies and a full range of services in reproductive health,
including family planning and sexual health (United Nations, 1995a,
chap. I, resolution 1, annex, para. 11.19). Achieving such an
objective requires that special attention be given to the following
priority areas:
(a) Data requirements, indicators and future research. The
development of appropriate mechanisms for collecting data and of
instruments for assessing and evaluating programme effects should
receive high priority. Assistance to country programmes for
developing or strengthening their information systems for the
management of information, education and communication programmes
should be a priority;
(b) Adolescents. Because of the critical stage of their
personal development, young people, particularly adolescents, have
a special need for information on sexual and reproductive health, as
well as on such other related issues such as substance abuse and
violence. Most young people are exposed to the mass media, classroom
education and the influence of their family members, peers and the
community at large and it is through these three principal channels
that they gain the information, education and skills required to
advance through the difficult passage to adulthood. The provision
of information about sexuality, pregnancy and sexually transmitted
diseases, combined with information about local services and
counselling availability, is an effective way of assisting young
people. Their participation in such activities can help ensure that
the messages are appropriate and compelling to their peers. They can
also be involved in facilitating the community dialogue and debate
that should be linked to those efforts. Youth organizations can also
play a major role in health promotion for youth both in and out of
school and contribute to making young people's immediate environment
more supportive. Youth groups can make linkages with the health
sector and help make health services more "youth-friendly". Such
organizations can also play a role in involving parents and helping
them understand and provide support to their adolescent children;
(c) Gender equality and equity. The Programme of Action affirms
that the full participation and partnership of both women and men is
required in reproductive life. Education and information that
promote such aims, along with responsible sexuality and respect for
women, are also fundamental to improving the status and role of women
in society. Increasing the education given to girls and women
contributes to their empowerment and to improved family health.
Expanding women's knowledge of reproductive health and expanding
their choices enables them to meet their reproductive goals.
Information, education and communication activities can contribute
to eradicating harmful practices against women and girls, such as
female genital mutilation; drawing attention to the health needs of
the girl child; eliminating nutrition practices that discriminate
against girls; involving men in reproductive health and family
planning programmes; removing barriers to women's rights and
enforcing legislation on early marriage, sexual exploitation and
violence; and in ensuring that women have equal access to education,
are guaranteed equal opportunity to work and receive equal pay for
equal work;
(d) Participation of programme users. Participation of
programme users in the design, implementation and evaluation of
information, education and communication programme interventions
increases the likelihood of the success of those programmes. Various
population groups have their own perspectives, ideas and opinions in
many areas, particularly about sexual and reproductive health issues.
Communicating effectively with them requires their direct
participation;
(e) Training of personnel. Health professionals should be
trained in basic information, education and communication matters to
cater to the special needs of the populations they serve, including
the areas of interpersonal communication, sexuality and counselling,
as well as team building, that will promote work with social welfare
workers, teachers, parents and community leaders. Training of
educators and student peers to work with other students in
educational and counselling activities should focus on techniques
dealing with problem-solving, listening, non-judgmental
communication, conflict resolution, decision-making, counselling and
basic education, as well as sexual and reproductive health needs.
Note
1/ Unsafe abortion is defined as a procedure for terminating
an unwanted pregnancy either by persons lacking the necessary skills
or in an environment lacking the minimal medical standards or both
(based on WHO, The Prevention and Management of Unsafe Abortion,
Report of a Technical Working Group (Geneva), WHO/MSM/92.5). This
definition was used in the Programme of Action of the International
Conference on Population and Development (Report of the International
Conference on Population and Development, Cairo, 5-13 September 1994
(United Nations publication, Sales No. E.95.XIII.18). References
Larsen, Ulla (1994). Sterility in sub-Saharan Africa. Population
Studies (London), vol. 48, No. 3 (November), pp. 459-474.
United Nations (1992). Abortion Policies: A Global Review, vol. I,
Afghanistan to France. Sales No. E.92.XIII.8.
(1993). Abortion Policies: A Global Review, vol. II,
Gabon to Norway. Sales No. E.94.XIII.2.
(1995a). Population and Development, vol. I,
Programme of Action adopted at the International Conference on
Population and Development, Cairo, 5-13 September 1994. Sales No.
E.95.XIII.7.
(1995b). World Population Prospects: The 1994
Revision. Sales No. E.95.XIII.16.
__________ (1995c). Women's Education and Fertility Behaviour:
Recent Evidence from the Demographic and Health Surveys. Sales No.
E.95.XIII.23.
(1995d). Abortion Policies: A Global Review, vol.
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(forthcoming). World Population Monitoring, 1996.
World Health Organization (1991). A tabulation of available data
on prevalence of primary and secondary infertility. Programme on
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the Frequency and Mortality of Unsafe Abortion, 2nd ed. Geneva.

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